A nurse is assisting in the care of a 60-year-old male client in a dialysis unit who reports fever, chills, and localized pain at the arteriovenous fistula (AVF) site.
Complete the diagram by dragging from the choices below to specify.
The Correct Answer is []
Condition: Sepsis.
2 actions:
Administer a broad-spectrum antibiotic,
Perform a swab culture of the AVF site.
2 parameters:
White blood cell count,
Blood cultures.
Rationale for correct condition: Sepsis is indicated by the client's fever, elevated heart rate, and respiratory rate, combined with signs of infection at the AVF site. Chronic conditions like diabetes and renal disease increase sepsis risk. The symptoms and history align with systemic infection spreading from the AVF site. Sepsis requires immediate intervention to prevent severe complications. Elevated temperature and infection signs suggest systemic involvement.
Rationale for actions: Administering antibiotics is crucial to control the infection. Swab culture identifies the causative organism. Indwelling catheter is unnecessary here. Aspirin does not treat infection. Bed rest alone is insufficient. Monitoring WBC count tracks infection response. Blood cultures confirm sepsis diagnosis. Creatinine is less urgent for immediate management. Blood glucose is relevant but not immediate. AVF site circumference monitors local rather than systemic infection.
Rationale for parameters: WBC count indicates immune response. Blood cultures identify bacteria, confirming sepsis. Creatinine is routine but not urgent. Blood glucose tracks diabetes control, less immediate. AVF circumference monitors local inflammation. Cellulitis is localized, not systemic. AVF thrombosis lacks systemic signs like fever. Endocarditis requires specific cardiac symptoms.
Rationale for incorrect conditions: Cellulitis does not explain systemic symptoms. AVF thrombosis lacks systemic infection signs. Endocarditis has distinct cardiac symptoms absent here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering ibuprofen to a client with thrombocytopenia is contraindicated because it can further impair platelet function and increase the risk of bleeding. Alternative pain management options should be considered.
Choice B rationale
Instructing the client to shave with a disposable razor increases the risk of cuts and bleeding. An electric razor is safer for clients with thrombocytopenia due to its lower risk of causing injury.
Choice C rationale
Protective isolation is not necessary for thrombocytopenia. It is primarily used for clients with severe immunocompromise to protect them from infections. Thrombocytopenia management focuses on bleeding prevention.
Choice D rationale
Checking the client for ecchymosis is important because it indicates spontaneous bleeding under the skin, which is a common complication of thrombocytopenia. Monitoring for signs of bleeding helps manage and prevent serious outcomes.
Correct Answer is ["A","C"]
Explanation
Choice A rationale: Allergy to penicillin can be a contraindication for administering cefazolin because of potential cross-reactivity between penicillins and cephalosporins. This client’s documented allergy to penicillin with symptoms of rash and throat swelling is significant and raises concern for a potential allergic reaction to cefazolin.
Choice B rationale: Elevated WBC count indicates an ongoing infection or inflammation, which is not a contraindication for cefazolin. Instead, it suggests the need for an antibiotic like cefazolin to manage the infection.
Choice C rationale: Prescription for furosemide is relevant because combining cephalosporins like cefazolin with diuretics like furosemide can increase the risk of nephrotoxicity. It’s important to consider the client’s renal function and monitor for potential kidney damage.
Choice D rationale: Fever >38.3°C is an indication for antibiotic therapy, not a contraindication. The elevated temperature suggests an infection that needs to be treated, making cefazolin appropriate in this context.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.